Thursday, April 23, 2009

Code Status

When I'm called in as a palliative medicine consultant, often the care team asks me to "clarify the patient's code status" or "get the DNR." Our default posture in medicine is that everyone gets CPR, defibrillation, cardiac drugs -- to steal a phrase from Zorba the Greek, "the full catastrophe" -- unless they specifically declare otherwise. CPR is an example of how medical ideas and technologies often sprint ahead of the evidence for their effectiveness. From a technique developed in operating rooms 50 years ago to restart hearts in otherwise healthy people, resuscitation has become enshrined in contexts for which it was never intended. Yet despite tweaking of the particulars over the years -- so many compressions to so many breaths, to pummel or not to pummel the breastbone with a closed fist -- survival after CPR is dismal, especially in the patients with life-limiting illnesses whom I see every working day.

Code status also is tied up in the admirable move away from paternalism in health care toward respect for patient autonomy. We doctors don't decide for you. You get to choose -- and that's a good thing. But the law of unintended consequences still applies and produces, well, unintended consequences. Now patients and their families are presented with menus -- do you want chest compressions? how about intubation? pressor medications to support the blood pressure? -- when they can't really understand the context of their choices.

Along with our profession's reluctance to dispense bad news (which I've commented on in previous posts), these two trends -- the kudzu-like proliferation of untested technology and the abdication of professional responsibility behind the smokescreen of autonomy -- combine in a perfect storm for patients and families facing life-limiting illness. Recently I consulted on a woman with widespread cancer who'd already chosen to enroll in hospice as soon as she was discharged from the hospital. But she had an episode of very low blood pressure, and the hospital's "rapid response team" rolled in with therapeutic guns blazing. As requested, I talked to the family about their mother's code status. They had a surprisingly nuanced view. They didn't want all the nasty, invasive stuff, but they did want us to make a reasonable effort to give them more time with their mom. When I reported this position outside the room, the nursing supervisor asked, "What about pressors?" The menu mentality was firmly ensconced. I pointed out that the family hadn't sliced and diced their reality that way, and that I felt they were relying on us to define what was reasonable. In reply I got some eye-rolling and a brief soliloquy on why that wasn't an acceptable response. Ultimately I picked up the challenge and said that "reasonable" meant "things that didn't require moving the patient to the ICU." That seemed to satisfy all parties. The patient's blood pressure stayed up, she went home on hospice the next day, and about twelve hours after discharge she died at home.

Another example, this time with an elderly patient whose every organ system was failing. The daughter -- wild-eyed, suspicious, and veering between anger and despair -- had already been offered the menu of choices instead of an honest appraisal of her mother's situation and her chances. She'd chosen a ventilator but none of the other stuff. No one had told her honestly that her mom's chance of getting off a ventilator once placed on it were somewhere between slim and none. How would things actually play out, I found myself wondering during my two-hour meeting with the daughter, if her mother actually did have a cardiac arrest? What would happen to the menu of choices? Would the rapid response team limit itself to intubation and a ventilator, or would the temptation to use other methods creep in? How did we get to this place, anyway?

As a hospice and palliative medicine physician, I can't do much about the unrelenting spread of medical technology in the absence of good evidence that it's effective. But I can try to do something about the menu problem. I'm tempted to try this approach: "If your heart stops and you die, do you want us to try to bring you back to life?" Blunt, perhaps, but closer to the truth than "Do you want pressors?"

About Me

I'm a full-time hospice and palliative medicine specialist in a fair-sized American city, providing palliative medicine specialty care to hospitalized patients. I also work in partnership with a local hospice program.